Which of the following would the nurse expect to see as symptoms in a child with ADHD?

Correct Answer: C

Rationale: Children with ADHD often display hyperactive and impulsive behaviors, such as excessive running, climbing, and fidgeting. These behaviors are characteristic symptoms of the hyperactive-impulsive subtype of ADHD. Children with ADHD may struggle to sit still, have difficulty engaging in quiet activities, and often seem on the go. Therefore, the nurse would expect to see signs of excessive movement and restlessness in a child with ADHD.

Correct Answer: A

Rationale: Turning and repositioning the patient every 2 hours is the most effective nursing intervention in preventing pressure ulcers in a patient with a history of stroke and immobility. Pressure ulcers, also known as bedsores, are caused by prolonged pressure on the skin, leading to reduced blood flow and tissue damage. By regularly turning and repositioning the patient, pressure is relieved from specific areas of the body, helping to prevent the development of pressure ulcers. This intervention helps to redistribute pressure, improve blood flow, and reduce the risk of skin breakdown, thus promoting skin integrity in immobile patients.

Correct Answer: C

Rationale: Ciprofloxacin is an antibiotic commonly prescribed for the prevention of bacterial infections that can result from animal bites, such as dog bites. Dog bites are often contaminated with bacteria and can lead to infections, particularly from organisms such as Pasteurella multocida. Ciprofloxacin is effective against a broad range of bacteria, including those commonly found in animal bites, making it a suitable choice for infection prophylaxis in this scenario. Ibuprofen is a pain reliever and anti-inflammatory medication, tetanus toxoid is given to prevent tetanus infection, and meperidine is a narcotic analgesic used for pain relief, but none of these options specifically target bacterial prevention in the case of a dog bite.

Correct Answer: C

Rationale: In a patient with ARDS who is experiencing refractory hypoxemia despite maximal ventilatory support and prone positioning, the use of extracorporeal membrane oxygenation (ECMO) is a potentially life-saving adjunctive therapy. ECMO works by providing temporary support for gas exchange outside the body, allowing the lungs to rest and heal while providing adequate oxygenation and carbon dioxide removal. The use of ECMO has been associated with improved oxygenation and reduced mortality in severe cases of ARDS, especially in patients who fail conventional therapies. High-frequency oscillatory ventilation (HFOV) has not consistently shown mortality benefit in ARDS, continuous renal replacement therapy (CRRT) is not directly indicated for hypoxemia in ARDS, and inhaled nitric oxide (iNO) has shown limited benefit in improving oxygenation in ARDS without a clear impact on mortality.

Correct Answer: B

Rationale: Human chorionic gonadotropin (HCG) can be detected in the blood as early as 10 days after the last menstrual period. This hormone is produced by the placenta shortly after the embryo attaches to the uterine lining. Pregnancy tests detect HCG levels to determine pregnancy status, and the hormone can be detected earlier in the blood compared to urine tests. Detecting HCG in the blood at around 10 days post ovulation is often the earliest point when a blood test can confirm pregnancy.

Correct Answer: B

Rationale: The nurse can assure Sandy that her new joint will function almost as well as a normal joint if she performs her exercises faithfully because post-joint replacement surgery recovery often involves physical therapy and exercises aimed at restoring strength and mobility to the affected joint. By following the recommended exercise regimen and post-operative care instructions, Sandy can improve the function of her new joint and achieve a good level of mobility and functionality, similar to that of a normal joint. It is important for Sandy to be diligent and committed to her rehabilitation process to maximize the benefits of the joint replacement surgery.

Correct Answer: A

Rationale: A retrospective audit involves reviewing past cases or data to evaluate processes, outcomes, or compliance with standards. In this scenario, the nursing team plans to audit post-op patients who developed pressure sores over the past year at the Orthopedic unit. By looking at historical data from the past year, the audit is considered retrospective as it assesses what has occurred over a specified period. This type of audit helps identify trends, patterns, and areas for improvement based on past events.

Correct Answer: B

Rationale: The correct charting rule to keep the nurse legally safe is to document worries and all concerns as verbalized by the patient (Choice I). This is important for accurately reflecting the patient's condition, communication, and potential interventions. Charting at the end of the shift only (Choice II) is not recommended as it can lead to missed important details or delayed documentation. Discussing recorded cases and diagnoses of the patient (Choice III) breaches patient confidentiality and violates HIPAA laws. Recording all information verbalized by the patient and family (Choice IV) may include unnecessary details and could potentially lead to misinterpretation or misunderstanding, which might not be legally advantageous.

Correct Answer: C

Rationale: The symptoms described in the scenario - chest pain, dyspnea, and cyanosis - are indicative of a potential air embolism. Air embolism occurs when air enters the bloodstream, leading to blockages in blood vessels and impeding oxygen delivery to tissues. In patients receiving Total Parenteral Nutrition (TPN) through intravenous lines, the risk of air embolism exists during line manipulations, disconnections, or improper priming of the tubing. The sudden onset of symptoms like chest pain and cyanosis in a patient on TPN should raise suspicion for an air embolism, as it requires immediate intervention to prevent further complications such as cardiac arrest or stroke.